24D-088 (13) BP-2022-0628
60 NORTH ST COMMONWEALTH OF MASSACHUSETTS
Map:Block:Lot:
24D-088-001 CITY OF NORTHAMPTON
Permit: Exterior Res
PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
BUILDING PERMIT
Permit# BP-2022-0628 PERMISSION IS HEREBY GRANTED TO:
Project# ROOF Contractor: License:
Est. Cost: 3000
Const.Class: Exp.Date:
Use Group: Owner: FREY JOHN D&JENNIFER K DIERINGER
Lot Size (sq.ft.)
Zoning: URC Applicant: FREY JOHN D&JENNIFER K DIERINGER
Applicant Address Phone: Insurance:
60 NORTH ST
NORTHAMPTON, MA 01060
ISSUED ON:06/02/2022
TO PERFORM THE FOLLOWING WORK:
RE-ROOF SECTION OF HOUSE
POST THIS CARD SO IT IS VISIBLE FROM THE STREET
Inspector of Plumbing Inspector of Wiring D.P.W. Building Inspector
Underground: Service: Meter: Footings:
Rough: Rough: House# Foundation:
Final: Final: Final: Rough Frame:
Gas: Fire Department Driveway Final: Fireplace/Chimney:
Rough: Oil: Insulation:
Smoke: Final:
THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND REGULATIONS.
Signature: 3-1
•
Fees Paid: $40.00
212 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Office of the Building Commissioner
xo g-,f'?, ( ,2/4_. , t ,ter
rFC
Commonwealth of Massachusett cil:k---
The *
Ir Board of Building Regulations and Sta i.rds
Massachusetts State Building Code, 7:,� CMr A=:�3` NIASEBuilding Permit Application To Construct,Repair,Renova - s d Ma 2011
One-or Two-Family Dwelling loN�
This Section For Official Use Only •�,�'F�ooNs
Building Permit Number: 3P-a .. 0 ), / Date Applied:
; If iov, )i • . I '''4' ____6/0a,
Building Official(Print Name) I Signature I ate
SECTION 1: SITE INFORMATION
1.1 Property Address: 60 .me S7' 1.2 Assessors p&Parcel Numbers ES
1.1 a Is this an accepted street?yes no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq ft) Frontage(ft)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public 0 Private 0 Zone: _ Outside Flood Zone? Municipal 0 On site disposal system 0
Check if yes❑
1 SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Record:
�oiv,— F ikto-Y '.„dyin lox A- 01040
Name(Print) City,State,ZIP v 1 /l
Akr,may` S)�r 4«adZ �
o-! oIt d rey.d aso'kel /,CaAl
No.an treet Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction 0 Existing Building 0 Owner-Occupied 0 Repairs(s)" Alteration(s) 0 Addition 0
Demolition 0 Accessory Bldg. 0 Number of Units Other 0 Specify:
Brief Description of Proposed Work2:
- till D,r r e_. ,
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Labor and Materials)
1.Building $ 1. Building Permit Fee:$ Indicate how fee is determined:
❑Standard City/Town Application Fee
2.Electrical $ ❑Total Project Cost3(Item 6)x multiplier x
3.Plumbing $ 2. Other Fees: $
4.Mechanical (HVAC) $ List:
5.Mechanical (Fire $
Suppression) Total All Fees 4 Lib
'3
Check No. eck Amount:
6.Total Project Cost: $ ll o o v 0 Paid in Full 0 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
License Number Expiration Date
Name of CSL Holder
List CSL Type(see below)
No.and Street Type Description
U Unrestricted(Buildings up to 35,000 cu.ft.)
R Restricted 1&2 Family Dwelling
City/Town,State,ZIP M Masonry
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
I Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
HIC Registration Number Expiration Date
H1C Company Name or HIC Registrant Name
No.and Street Email address
City/Town,State,ZIP Telephone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152.§ 25C(6))
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide
this affidavit will result in the denial of the Issuance of the building permit.
Signed Affidavit Attached? Yes ❑ No 0
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I,as Owner of the subject property,hereby authorize
to act on my behalf,in all matters relative to work authorized by this building permit application.
Print Owner's Name(Electronic Signature) Date
SECTION 7b:OWNER' OR AUTHORIZED AGENT DECLARATION
By entering y e ow,I hereby attest under the pa', and penalties of perjury that all of th 'nformation
contained' this pp' 'on is tru- and a/ urate to : 9- t of my knowledge and understanding.
Print Owner's Authorized Agent's Name(Elecic Signature) Date
NOTES:
1. An Owner who obtains a building permit to do his/her own work,or an owner who hires an unregistered contractor
(not registered in the Home Improvement Contractor(HIC)Program),will not have access to the arbitration
program or guaranty fund under M.G.L.c. 142A.Other important information on the HIC Program can be found at
www.mass.gov/oca Information on the Construction Supervisor License can be found at www.mass.gov/dps
2. When substantial work is planned,provide the information below:
Total floor area(sq.ft.) (including garage,finished basement/attics,decks or porch)
Gross living area(sq. ft.) Habitable room count
Number of fireplaces Number of bedrooms
Number of bathrooms Number of half/baths
Type of heating system Number of decks/porches
Type of cooling system Enclosed Open
3. "Total Project Square Footage"may be substituted for"Total Project Cost"
The Commonwealth of Massachusetts
Department of Industrial Accidents
1 Congress Street,Suite 100
Boston,MA 02114-2017
www.mass.gorldia
Workers'Compensation Insurance Affidavit BuildersiContractorsiElectricianalPlumbers.
TO RE FILED WITH THE PERMITTING AUTHORITY,
Applicant Information Please Print Leeibls
Name(BusinessIkganizationindividual):
Address:
City/State/Zip: Phone#:
Are yea an emptily er?Check the appropriate hot: Type of project(required):
1.E3 1 ania erapkryer with employees lull anikie 7. New construction
21711atn sok proprietor or pannership and have no anployees working for me in R. Remodeling
.ta:,capacity.[?..40 totter C4Anp.imunince required.)
'4,1 ant a Kaiseowner doing all work myself.'No workers'comp. insurance required)' 9. 0 Demolition
100if Building addition
.in a homeowner and will 1w hiring svintractors to conduct all work on tw property. I will
• ensure that all ciintraenns either have weighers'wive/is-aim insurance or are sole II Electrical repairs or additions
proprietors with no employees.
12.0 Plumbing repairs or additions
taut a general contractor and I have hued the stub-contractors hated on the attached sheet
13 CI Roof repairsThese sub-einitractors hat employees and have workers'comp.insurance.:
Ena We are a melioration and its officers have exiatised their right of exemption per MGLc. 14. l Other
152,§1{4).arid we tuts c no ianployees.[No workers'comp.insurance to:quinta]
•Any applicant that checks,box ttl must atau all out the waitron bdtnt%him mg their workers compensation policy Mformation.
f tiomeowitem who subisnit this affidavit indicating they are doing all work and then hire outside cositracuors must submit a new alTidav it and imung such_
It'ontractors that eked.this bus must attachkil an additional skeet show ing the name of the sub-coraractor,and state w liether or not those eiititen have
,rirlo?,,,•="' It tive sub-conlractur>base cmplo.,.ets tlir.5 ruusi pros kit-their %others'cramp pvta number
I am an employer that is providing h'orliers'compensation insurance for my employees. Below is the polity and Job site
information.
Insurancc Company Nante:
_ -
Policy#or Self-ins.Lic.#: Expiration Date:
Job Site Address: City/State/Zip:
Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under MGL c. 152, §25A is a criminal violation punishable by a fine up to S1,500.00
ancVor one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a
day against the violator.A copy of tins Ntatement may be forwarded to the Office of Investigations of the DIA for insurance
coverage verifi iI.
I do hereby rrifr sin 'er pl .n.$ lin p amities ofper. that the information provided ab v is true and correct.
Sienaturc. K,7) Date:
Phunc
Official use only. Do not write in this area,to be completed kr city or town official
('its or Ton: Permit/License#
Issuing Authority (circle one):
1. Board of Health 2.Building Department 1 City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.other
Contact Person: Phone#:
City of Northampton
41" Massachusetts ?
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+` DEPARTMENT OF BUILDING INSPECTIONS ;=
w+ y'mr ` 212 Main Street • Municipal Building Jti �D
Northampton, MA 01060 ss 1-DNA
4,
CONSTRUCTION DEBRIS AFFIDAVIT
(FOR ALL DEMOLITION AND RENOVATION PROJECTS)
In accordance of the provisions of MGL c 40, S54, a condition of Building Permit
Number is that all debris resulting from this work shall be disposed of
in a properly licensed waste disposal facility, as defined by MGL c 111, S 150A.
The debris will be disposed of in:
V f:ec f
Location of Facility: Y
The debris will be transported by:
Name of Hauler:
Signature of Applicant: Date: ✓' ��
City of Northampton
',; 71 4 s
C
h Massachusetts �,,'' .1.._ 'e
li
1DEPARTMENT OF BUILDING INSPECTIONS �°
,. 212 Main Street • Municipal Building ',I-
_
Northampton, MA 01060 JJ'zyF, 3
G HOMEOWNERS'EXEMPTION LIGIBILITY AFFIDAVIT
I 1iv� (insert full legal name), born (insert
month, day, year), hereby depose and state the lowing:
1. I am seeking a building permit pursuant to the homeowners'exemption to the permit requirements of the
Massachusetts State Building Code, codified at 780 CMR 110.R5.1.3.1, in connection with a project or
work on a parcel of land to which I hold legal title.
2. I am not engaged in, and the project or work for which I am seeking the aforementioned homeowners'
exemption, does not involve the field erection of manufactured buildings constructed in accordance with
780 CMR 110.R3.
3. I qualify under the State Building Code's definition of"homeowner"as defined at 780 CMR 110.R5.1.2:
Person(s) who owns a parcel of land on which he/she resides or intends to reside, on which
there is, or is intended to be, a one-or two-family dwelling, attached or detached structures
accessory to such use and/or farm structures. A person who constructs more than one home in
a two-year period shall not be considered a home owner.
4. I do not hold a valid Massachusetts construction supervision license and, except to the extent that I
qualify for and will abide by the Massachusetts State Building Code's requirements for the supervision of
the project or work on my parcel, I am not engaged in construction supervision in connection with any
project or work involving construction, reconstruction, alteration, repair, removal or demolition
involving any activity regulated by any provision of the Massachusetts State Building Code.
5. If I engage any other person or persons for hire in connection with the aforementioned project or work on
my parcel, I acknowledge that I am required to and will act as the supervisor for said project or work.
Si:4'•d and• the pa'a s and pp-• ties of perjury on this 1 day of 2 ' g
ii . �—